This form is required to be filed for employee benefit plans under sections 104 and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and sections 6047(e), 6057(b), and 6058(a) of the Internal Revenue Code (the Code).

Complete all entries in accordance with the instructions to the Form 5500.

Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.

Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including accompanying schedules, statements and attachments, as well as the electronic version of this return/report, and to the best of my knowledge and belief, it is true, correct, and complete.

SIGN HERE

YYYY-MM-DDABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Signature of plan administrator

Date

Enter name of individual signing as plan administrator

SIGN HERE

YYYY-MM-DDABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Signature of employer/plan sponsor

Date

Enter name of individual signing as employer or plan sponsor

SIGN HERE

YYYY-MM-DDABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Signature of DFE

Date

Enter name of individual signing as DFE Preparer’s name (including firm name, if applicable) and address; include room or suite number. (optional)

Number of participants with account balances as of the end of the plan year (only defined contribution plans complete this item) ....................................................................................................................................................................

6g

123456789012

h

Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested ..............................................................................................................................................................

6h

123456789012

7

Enter the total number of employers obligated to contribute to the plan (only multiemployer plans complete this item) .........

7 8a

If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristics Codes in the instructions:

b

If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristics Codes in the instructions:

9a

Plan funding arrangement (check all that apply)

9b

Plan benefit arrangement (check all that apply)

(1)

X

Insurance

(1)

X

Insurance

(2)

X

Code section 412(e)(3) insurance contracts

(2)

X

Code section 412(e)(3) insurance contracts

(3)

X

Trust

(3)

X

Trust

(4)

X

General assets of the sponsor

(4)

X

General assets of the sponsor

10

Check all applicable boxes in 10a and 10b to indicate which schedules are attached, and, where indicated, enter the number attached. (See instructions)

This schedule is required to be filed under section 104 of the Employee Retirement Income Security Act of 1974 (ERISA).

File as an attachment to Form 5500.

OMB No. 1210-0110

2012

This Form is Open to Public Inspection.

For calendar plan year 2012 or fiscal plan year beginning and ending Name of plan

BCDEFGHI

B

Three-digit plan number (PN)



001

C

Plan sponsor’s name as shown on line 2a of Form 5500

BCDEFGHI

D

Employer Identification Number (EIN)

12345678

Part I

Service Provider Information (see instructions)

You must complete this Part, in accordance with the instructions, to report the information required for

each person

who received, directly or indirectly, $5,000 or more in total compensation (i.e., money or anything else of monetary value) in connection with services rendered to the plan or the person's position with the plan during the plan year. If a person received

only

eligible indirect compensation for which the plan received the required disclosures, you are required to answer line 1 but are not required to include that person when completing the remainder of this Part.

1 Information on Persons Receiving Only Eligible Indirect Compensation a

Check "Yes" or "No" to indicate whether you are excluding a person from the remainder of this Part because they received only eligible indirect compensation for which the plan received the required disclosures (see instructions for definitions and conditions).. . . . . . . . . . . . . . .

X

Yes

X

No

b

If you answered line 1a “Yes,” enter the name and EIN or address of each person providing the required disclosures for the service providers who received only eligible indirect compensation. Complete as many entries as needed (see instructions).

(b)

Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

(b)

Enter name and EIN or address of person who provided you disclosure on eligible indirect compensation

(b)

Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

(b)

Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500Schedule C (Form 5500) 2012v.120126